Some upheld, recommendations

Summary

Mr C attended his dentist for a routine check-up. During this check-up the dentist intended to scale and polish Mr C's teeth (a procedure where tartar build-up is removed from the gumline). Mr C refused, as a previous treatment had caused sensitivity to his teeth. The dentist advised Mr C that if he was unable to perform the treatment necessary then he could no longer provide treatment to Mr C and would remove him from his patient list.

Mr C complained that the dentist had not followed the correct procedures in de-registering him and the reason for de-registering him was unreasonable.

We sought independent advice from a dental adviser. The adviser explained the procedure for de-registering a patient, which involves contacting the local health board. The dentist was unable to provide evidence the correct procedure was followed and we upheld this complaint and made recommendations.

The adviser said that it was an individual clinical decision for the dentist to make about whether the relationship had broken down to the point where they could no longer treat the patient. Therefore, we did not uphold Mr C's second complaint.

Recommendations

We recommended that the dentist:

• revise the guidance on de-registering patients; and
• put in place a system for evidencing that the correct procedure is followed.

Summary

Mr C experienced dizziness and balance problems after an operation on his ear in 2007. In 2012 he was referred to Glasgow Royal Infirmary's ear nose and throat (ENT) department. After examining Mr C, the ENT consultant wrote to the GP saying that he could find no physical cause of Mr C's symptoms. He referred Mr C to the Royal Alexandra Hospital for specialist tests, but commented that he felt some of Mr C's symptoms were not genuine. The specialist tests identified that Mr C had an almost complete loss of vestibular function (the system in the ear that contributes towards balance) in his left ear. Mr C complained that the ENT consultant in the first hospital did not carry out appropriate diagnostic tests or provide suitable treatment for his condition. He also complained that the second hospital did not keep his GP adequately informed of the tests that he was undergoing or his diagnosis.

We took independent advice from one of our medical advisers, who is a consultant ENT surgeon. Although we were critical of the ENT consultant's comments in his letter to Mr C's GP, we were generally satisfied that he assessed Mr C's condition appropriately and made a suitable referral for specialist treatment. That said, we took the view that he could have given more consideration to the need for a magnetic resonance imaging scan (used to diagnose health conditions that affect organs, tissue and bone), and the potential effects of Mr C's existing medication. We were satisfied that Mr C's GP was provided with adequate information about the investigations into his symptoms and his ongoing treatment.

Recommendations

We recommended that the board:

• apologise to Mr C for the ENT consultant's suggestion that his symptoms were not genuine; and
• share our decision with the ENT consultant with a view to identifying any points of learning.

Summary

Ms C complained about the care and treatment her mother-in-law (Mrs A) received while a patient in the Victoria Hospital in the days immediately before her death. Mrs A had a history which included, amongst other things, epilepsy and dementia.

Mrs A was admitted to the hospital after a fall from bed. She then fell a further twice from bed, and shortly after the second time, she sustained a serious injury and subsequently died. Ms C said that the hospital failed to protect her mother-in-law properly, particularly as Mrs A had been assessed as being at high risk from falls. She said Mrs A was not provided with the one-to-one care she should have been given nor was she given appropriate medical care after she fell from bed. Ms C was also concerned at the level of communication with the family because although they were advised of both falls, the second time there was no sense of urgency despite Mrs A's very serious condition.

We took independent advice from a consultant geriatrician and from our nursing adviser. We found that the medical care Mrs A received was reasonable, so did not uphold that aspect of her complaint. However, we found that nursing staff failed to provide Mrs A with adequate nursing care; there was a general lack of detail in some of Mrs A's records; and there was a similar lack of detail given to the family about Mrs A's condition, so we upheld all of Ms C's complaints about these issues.

Recommendations

We recommended that the board:

• formally apologise to Ms C for their shortcomings in nursing care;
• confirm to us that the recommendations they made, after a significant adverse event review, have been satisfactorily completed;
• ensure that all staff are reminded of their obligations to provide properly detailed notes and demonstrate to us that they have done so;
• apologise for their communication failures; and
• remind staff on the relevant ward of the necessity of good, clear communication with patients' families, particularly in circumstances where the patient is unable to make their own decisions.

Summary

Mrs C complained about the palliative care provided to her father (Mr A) after his dialysis treatment (a form of treatment that replicates many of the kidney's functions) was stopped. Although this decision was discussed with the family, the hospital did not tell Mr A's medical practice about this, so they only found out three weeks later during a visit to Mr A's care home. At this stage, the GP began palliative care, including prescribing fentanyl patches (a type of pain relief similar to morphine). However, another GP stopped the fentanyl patches a few days later, and did not prescribe any other pain relief. Mrs C was concerned about this, and contacted the hospital consultant. The consultant tried to contact the practice, but the practice did not call back until the next day. After speaking with the consultant, the practice arranged an infusion pump of a painkiller and sedative for Mr A.

After taking independent medical advice from one of our GP advisers, we upheld one of Mrs C's two complaints. We found the practice could not have known that Mr A required palliative care earlier (as the hospital was responsible for telling them), and when they did find out, their care was reasonable, based on Mr A's symptoms at the time. It was also reasonable for the practice to return the consultant's call the next day, as there was no evidence that the message was given as urgent. However, we were critical that the GP did not discuss the decision to stop the fentanyl patches with Mr A's welfare attorney (his wife). We were also critical that the practice gave Mrs C misleading information, as they told her that, if they had known the dialysis was stopped, they would have referred Mr A to the community palliative care team, but they later told us that this wasn't necessary in Mr A's case.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings our investigation found; and
• bring the findings of our investigation to the attention of the doctor involved for reflection as part of their next annual appraisal.

Summary

Ms C had cognitive and communication problems. Following poor experiences with her GP practice, she asked to be deregistered. However, she subsequently found it difficult to register with a new practice. Before registering with a new GP, Ms C sought reassurance that they would make reasonable adjustments in light of her disabilities to allow her to access the services she required. On each occasion, the local GP practices asked her to register first so that her needs could be assessed and adjustments put in place. Ms C was reluctant to do so and asked the board for help. Whilst the board provided details of local practices, they also advised that she should register first to allow a needs assessment.

Ms C complained that the board did not make reasonable adjustments to help her access services in her community. She also complained about their handling of her correspondence and that they labelled her a vexatious complainant.

We were satisfied that the board acted reasonably by signposting Ms C to local GP practices and advising her to register. We found that equalities legislation requires practices to make such adjustments as are necessary, reassuring patients that adaptations will be made to allow them to access services.

We were critical of the board's handling of Ms C's correspondence, so we upheld this aspect of her complaint. Her correspondence was treated as a complaint but was not progressed through the formal complaints process. However, we did not find that Ms C had been categorised as a vexatious complainant.

Recommendations

We recommended that the board:

• apologise to Ms C for the poor handling of her correspondence;
• review their handling of Ms C's correspondence and consider how best to progress matters that are addressed outwith the formal complaints procedure; and
• remind their staff of the importance of adhering to the NHS Scotland complaints procedure.

Summary

Ms C complained about the care and treatment that her late brother (Mr A) received during two admissions to University Hospital Ayr. She felt he was inappropriately discharged on the first occasion and that the board had not communicated adequately or provided appropriate treatment during his second admission. During that admission, Mr A died and, although Ms C explained that her family were aware that he had been most unwell, she felt the board's care was unreasonable.

As part of our investigation we took independent advice from one of our medical advisers. He explained that Mr A had been suffering from serious liver disease and the outlook for him was poor. However, it was unclear from the medical records why a proposed course of treatment during his first admission was not administered. The notes said Mr A would be given medication if a particular test result was above a certain level, which it was. On balance, therefore, we upheld Ms C's first complaint and made two recommendations.

In terms of Mr A's second admission, our adviser explained that in such situations it is difficult to decide when it is appropriate to move to palliative care (care to prevent or relieve suffering only). However, staff had acted in line with appropriate guidance. Although we recognised the significance of this for Mr A's family, we found no evidence that Mr A's care was unreasonable or of an unreasonable delay in moving to palliative care. The evidence about communication was limited, but our adviser said that the records pointed to conversations with Mr A's family that reflected his condition at those times. Although we took Ms C's concerns into account we did not find that the evidence, viewed as a whole, indicated that the board failed to communicate adequately. We did not uphold these complaints.

Recommendations

We recommended that the board:

• ensure the staff involved in this case reflect on the need to communicate and consider all relevant test results prior to discharge; and
• remind clinical staff of the importance of ensuring records reflect a patient's treatment plan, particularly where the plan changes (where reasonably practicable in the circumstances).

Summary

Mr C complained about the care and treatment provided to his mother-in-law (Mrs A) in Crosshouse Hospital before her death. Mrs A had dementia and had contracted clostridium difficile (C diff - a common healthcare-associated infection), which caused severe diarrhoea. Mr C complained that staff had failed to maintain Mrs A's personal hygiene. He said that they had not changed her often enough and that her hands were covered in her own faeces.

We took independent advice from our nursing adviser. The combination of Mrs A's dementia and severe diarrhoea had caused problems for staff and distress for her family. However, we found that staff had carried out frequent checks on Mrs A and had taken reasonable steps to maintain her personal hygiene. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that staff failed to ensure that Mrs A's food or fluid was provided at the appropriate consistency. We found there had been problems with fluid consistency, and that there was delay in prescribing a dietary supplement. In view of these failings, we upheld this aspect of Mr C's complaint. However, the board sent us an action plan showing that refresher training on the provision of thickened fluids had been provided to staff. They had also apologised to Mr C for the shortcomings in Mrs A's care.

Finally, Mr C complained that staff failed to make adequate arrangements for Mrs A's discharge. We found that there should have been a multi-disciplinary meeting with social work and the family invited to attend before Mrs A was discharged, but that staff had failed to arrange this. In view of this, we also upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to ensure that, where appropriate, patients are promptly referred to the dietician for review;
• provide evidence to confirm that steps have been taken to ensure that, when appropriate, discharge planning meetings take place for patients in the ward and that relatives are included in the discharge planning process; and
• offer to meet with Mrs A's family to discuss the complaint and the steps taken to address the failings identified.

Summary

Mr C’s business premises were located below a block of tenement flats. The flats’ courtyard formed the roof of his premises. His business was identified as a gap site (a business that is receiving water services, but is not being charged) and Business Stream was appointed as his licensed provider of water services. An invoice was issued based on the business’s estimated water usage. Mr C queried the amount he was charged. He explained to Business Stream that there was a water meter in place (although it was unreadable) and that his business used only a very small amount of water. He also questioned whether he should be charged for roads and property drainage given that his premises had no roof of its own.

Had the meter in Mr C’s premises been installed by Scottish Water, his business should have been billed based on his metered water usage rather than an estimate. We found that, although it had been confirmed that a meter was in place, this was badly corroded and it was not possible to confirm whether this had originally been installed by Scottish Water. We were satisfied that Business Stream made reasonable efforts to confirm whether this was a Scottish Water meter, however, we accepted that there was insufficient evidence available for them to accept responsibility for the equipment. We were critical of Business Stream for a subsequent delay in replacing the meter and commencing metered charges.

We found the charges for property and roads drainage to be reasonable. To avoid such charges, it is the customer's responsibility to provide evidence that water is not transported away from their premises via the public sewer network. No such claim had been made by Mr C. That said, we asked Business Stream to contact Mr C with details of what evidence would be required to pursue this matter further.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for the delay to installing a new meter at his business's premises;
• recalculate Mr C's water charges for the period in question based on his metered average daily usage rate and refund any overpayments on his account; and
• write to Mr C explaining fully the reasons for their property and roads drainage charges and the type of evidence that would be required from him should he still feel that the charges are incorrect.

Summary

Mr C was suspected of assaulting another prisoner (Mr B). A disciplinary hearing was held and Mr C was found guilty. Mr C appealed this finding on the basis that the adjudicator had accepted verbal evidence from two prison officers, which Mr C said had been fabricated. Mr C was also dissatisfied that his request to have Mr B present as a witness at the appeal hearing was rejected, and that his complaint was not properly dealt with by prison staff.

We did not uphold Mr C's complaints about evidence and the witness. We found that it was reasonable and in accordance with the prison rules for the adjudicator to accept the verbal evidence from the two prison officers, given that their recollection of events was provided within 24 hours of the assault allegations having been raised and investigated. We also considered that the adjudicator had taken into account additional evidence from CCTV footage and from Mr C's response at the disciplinary hearing. In relation to Mr C's request to have Mr B attend the appeal hearing, we considered it was reasonable for Mr B not to have attended for his personal safety. The chair took steps to find out from Mr C what he wanted to ask Mr B, and shared this information with Mr C at the disciplinary hearing.

We concluded that the appeals form provided misleading information to Mr C that he could also complain about the finding of guilt through the Scottish Prison Service's complaints procedure. This is contrary to the prison rules and Scottish Ministers' Directions which set out that a prisoner must be signposted to us if they remain unhappy with the outcome of the appeal hearing. We upheld this complaint and made a recommendation.

Recommendations

We recommended that Scottish Prison Service:

• ensure the wording set out in the appeals paperwork is amended to take into account the relevant prison rules and Scottish Ministers' Directions.

Summary

Mr C's wife (Mrs C) is a landlord. Mr C complained on her behalf about the way the panel handled a referral made to them by her tenant concerning the landlord's duty to meet the repairing standard under the Housing (Scotland) Act 2006. Mr C was unhappy with the administrative handling of the matter and complained that, by the time he was advised about the referral, the tenant had left the property and the repairs required to the property had been completed. He was also unhappy with the handling of his correspondence, that the panel had failed to advise him of progress on the case, and that they had failed to notify him about the possibility of mediation. He also complained that they had failed to deal with his complaint under their complaints process.

The panel are subject to legislative provisions which govern their procedures. We were satisfied that based on the available evidence the panel had processed the referral made to them by the tenant in line with relevant legislation and did not uphold the complaint. The panel had accepted that they had failed to reply to some correspondence and, as a result, had failed to keep Mr C advised of progress on the matter. We were, however, satisfied that in this case, mediation had not been appropriate. Finally, while the panel had responded to Mr C's complaint, we noted that they had failed to clarify what stage in their process Mr C had reached and failed to advise him of his right to come to this office at the conclusion of the process.

Recommendations

We recommended that the panel:

• remind staff of the need to explain to complainants early in the process what stage their complaint is at and ensure they are notified of their right to complain to the SPSO at the conclusion of the complaints process.